Provider Demographics
NPI:1275677742
Name:BEASLEY, PATRICIA K (MS, RD, LDN, CCN)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:K
Last Name:BEASLEY
Suffix:
Gender:F
Credentials:MS, RD, LDN, CCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5270 SIX FORKS RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-4432
Mailing Address - Country:US
Mailing Address - Phone:919-782-4181
Mailing Address - Fax:
Practice Address - Street 1:5270 SIX FORKS RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-4432
Practice Address - Country:US
Practice Address - Phone:919-782-4181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL000937133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC144CCOtherBCBSNC PROVIDER #